1. Software Failures Ron Gilmore, CMC Edmonton April 2006

2. Software Failures Santayana The software sector Observations Case Study:Therac 25 Lessons Engineering Comparisons Challenges

3. Santayana (1863 - 1952) Philosopher, essayist, poet, novelist The Life of Reason (1905) "Those who cannot remember the past are condemned to repeat it“ Lots of other great quotes Egypt, March 2006

4. Software Sector Young – less than a century Amateurs Change, churn and failures Compare to roads, houses, bridges Professions evolving Standards evolving Best practices evolving Societal awareness evolving

5. Case Study: Therac 25 Radiation therapy machines Atomic Energy of Canada 1985 to 1987 Six known “incidents” Massive radiation overdoses to patients Order of tens of thousands of rads At least five deaths!

6. Therac 25 Root Causes Institutional causes: –No independent code review –Software not included in reliability design –Documentation “lean” on error codes –AECL did not initially believe complaints

7. Therac 25 Root Causes Design Issues: –No preventative hardware interlocks –AECL re-used software from older models which had hardware interlocks –No way for software to verify sensors were working –Arithmetic overflow - safety checks bypassed –Software written in assembly language

8. Therac 25 Lessons? Professions? Standards? Best practices? Societal awareness?

9. Engineering Comparisons More mature sector Certification, legislation, compliance Curriculum: Tacoma Narrows Bridge Still: London Pedestrian bridge Still: Confusion re mandate, coverage Still: budget & schedule - oilsands

10. Challenges Education – technical, business Sensitivity – bad software can kill! Lots more examples: –Chinook helicopter –Missile detection systems

11. Constructive Notions Awareness efforts Consequences Core competencies Systems classifications: –A = Life threatening –B = Business threatening –C = Other